1. Jean West MSW LCSW CTC-S CT SITCAP as an Intervention with the Homeless

2. What is Trauma? Trauma is an overwhelming sense of terror, powerlessness and the absence of a sense of safety.

3. Exposure Following exposure to a potentially trauma inducing incident, survivors may become frozen in an activated state of arousal. Arousal refers to a heightened state of alert and fear for one’s safety. Experiences

4. Experiences which can cause trauma Physical and/or sexual abuse Domestic violence Living with substance abusing parents Witnessing parental homicide Homelessness Burns/other serious accidents Car fatalities Divorce Natural disasters

5. Perception

6. “When it comes to trauma, the critical factor is the perception of threat and the incapacity to deal with it.” Levine 2005 Perception

7. Three Types of Trauma Type I Single exposure/posttraumatic growth likely/positive psychological outcome likely/survivor versus victim Type II Single incident like abuse repeated over chronic period / multiple exposures/PTG accessible/can separate one incident from another/impaired functioning but manages Type III Complex cumulative trauma/ can’t separate out memories/trait and state anxiety/generational transmission/psychiatric disorders/low functioning

8. Posttraumatic Stress Disorder According to the DSM-IVTR, in order for a child to be diagnosed with PTSD, two characteristics must exist: The person experienced, witnessed, was related to, or was confronted with an event or events that involved actual or threatened death or serious injury or threat to the physical integrity of self or others. The person(s) response involved intense fear, helplessness or horror…

9. The Role of the Brain and the Nervous System

10. So what does trauma do to the developing brain? Sympathetic nervous system takes over. Cortisol and adrenaline goes up and stays up and acts like an acid rain on the rest of the nervous system. Suppressed serotonin levels Affect dysregulation Depressed executive function organization, planning,

11. Traumas Effect on Learning In the arousal (anxious) state it becomes difficult to process information, follow directions, recall information, and focus Physician’s office Poor problem solving, attention, disorganized Often only hear half of the words spoken by their teachers Cognitively will generally be far behind their peers, children can often learn at three times the rate compared to when engulfed in trying to survive

12. Traumas Effect on Behavior Hypervigilance Difficulty sleeping Easily startled Clinging Nightmares Disobedience Impaired social skills Anger /rage Can’t self sooth or modulate emotions Depression Attention problems Impulsivity Aggression Fearful Risk taking Panic attacks Hypersensitive to touch, movement, some sounds and smells

13. Secondary Victimization or Wounding Secondary victimization or wounding occurs when the people and organizations you turn to for help respond in subtle ways that cause you additional pain. Denial and disbelief Discounting and minimizing Blaming you Treating you as defective

14. Trauma and Homelessness “Trauma- physical, sexual, and emotional –is both a cause and a consequence of homelessness.” HCH 1999

15. Trauma and Homelessness cont… “The experience of homelessness can be best understood as highly stressful, and, in some instances, traumatic. While homelessness is enormously stressful to individuals of any age, children’s experiences are unique in that it involves multiple losses during critical developmental periods. Children who are homeless are likely to be forced to leave behind valued possessions, experience disruptions in friendships and other significant relationships, and both change and infrequently attend school. Additional emotional strains are tied to enduring the social stigma of homelessness.” Cowan 2007

16. Impact of Homelessness on Children Every day, homeless children are confronted with stressful, often traumatic events. 74% of homeless children worry they will have no place to live. 58% worry they will have no place to sleep. 87% worry that something bad will happen to their family. (Impact on education, trauma)

17. Impact cont… Within a single year: 97% of homeless children move, many up to three times. More than 30% are evicted from their housing. 22% are separated from their family to be put in foster care or sent to live with a relative. Almost 25% have witnessed acts of violence within their family.

18. Mental Health The constant barrage of stressful and traumatic experiences has profound effects on the cognitive and emotional development of homeless children. Homeless babies show significantly slower development than other children do. Homeless children between 6 and 17 years struggle with very high rates of mental health problems.

19. The Emotional Impact More then one-fifth of homeless preschoolers have emotional problems serious enough to require professional care, but less then one-third receive any treatment. Homeless children have twice the rate of learning disabilities and three times the rate of emotional and behavioral problems as nonhomeless children. Half of school-age homeless children experience anxiety, depression, or withdrawal compared to 18% of nonhomeless children. By the time homeless children are eight years old, one in three has a major mental disorder. NCTSN 2005

20. Homeless Children and abuse 8% have been physically abused, twice the rate of other children. 8% have been sexually abused; three times the rate of other children. 35% have been the subject of a child protection investigation. 24% have witnessed acts of violence within their family. 15% have seen their father hit their mother. 11% have seen their mother abused by a male partner. National Center on Family Homelessness

21. Teens Homeless youth exhibit psychiatric disorders at a rate six times greater than the general youth population, with between 66 and 89 percent of homeless youth having symptoms of one or more disorders. Whitbeck, 2009

22. Subgroups even more at risk Within the homeless youth population there are certain sub-groups who are the most at risk for developing a mental illness. Gay, lesbian, bi-sexual, and transgender youth appear to have the most pervasive mental health problems. Youth who have been in state care Youth who have histories of abuse.

23. Profound Effects Taken individually or cumulatively, the experiences of homelessness are likely to have profound effects on children’s social, emotional and cognitive development. (Anooshian, 2005; Bassuk, Buckner, et al, 1997

24. Homeless Fathers Although 70% of fathers of homeless children are in touch with their children, most do not live with the family. The downward spiral into homelessness for a child is often accelerated if a father loses his job, becomes injured or ill, has a bout with alcohol or drugs, or is involved with the criminal justice system. 50% of fathers are unemployed. 43% have problems with drugs or alcohol. 31% have physical or mental health problems. 32% are in jail or on probation.

25. Homeless Mothers

26. Violence The frequency of violence in the lives of homeless mothers is staggering. 63% have been violently abused by an intimate male partner. 27% have required medical treatment because of violence by an intimate male partner. 25% have been physically or sexually assaulted during adulthood by someone other than an intimate partner. 66% were violently abused by a childhood caretaker or other adult in the household before reaching 18. 43% were sexually molested as children.

27. Connection Homelessness by itself can trigger significant mental and emotional problems as trauma on the streets can result in major depressive disorders, post traumatic stress disorder, substance abuse, conduct disorder and even suicide.

28. Trauma and Homelessness Cont… Homelessness results in a loss of community, routines, possessions, privacy, and security. According to The National Traumatic Stress Network, more than 90% of sheltered and low-income mothers have experienced physical and sexual assault over their lifespan. The experience of homelessness puts families in situations where they are at greater risk of additional traumatic experiences such as assault, witnessing violence, or abrupt separation. The stresses associated with homelessness can exacerbate other trauma-related difficulties and interfere with recovery due to ongoing traumatic reminders and challenges. NCTSN 2005

29. Trauma and Homelessness Cont… Trauma is THE predominant mental health issue for homeless mothers. Research confirms that the strongest predictor of emotional and behavioral problems in poor and homeless children is their mother’s level of emotional distress. HCH 2003 (resiliency research with TLC) Emotional help is needed for both the parents and their children in order to be most effective.

31. SITCAP: Primary Issues with Trauma Fear / Terror Worry Hurt Anger Revenge Accountability Power Safety Survivor vs. Victim

32. Drawing Draw me a picture of what happened that you can tell me a story about. Psychomotor activity that helps to trigger the sensory memories when it is trauma focused Engages the child in active involvement in their healing Helps us to see what the child sees Helps the child externalize the experience and move it to a safe place (the paper) outside himself which he has control over

33. Drawing cont… Provides visual representation To communicate visually what we do not always have words to describe Safe vehicle to communicate details Recreates a renewed sense of power and safety which gives them hope for the future

34. Questions to Elicit Details After the child has drawn their experience, begin to ask trauma-specific questions about the story What do you remember seeing or hearing? Do you sometimes think about what happened even when you don’t want to? Do certain sounds, smells, etc… suddenly remind you of what happened? What would you like to see happen to the person or thing that caused this to happen? Do you sometimes think it should have been you instead?

35. Symptoms Versus Behaviors Reduction of PTSD symptoms can be experienced without focusing on symptoms. Begin to restore a sense of safety and power in the child and symptoms will diminish.

36. Use of SITCAP in a shelter Children individual assessments, groups Parents trainings, support group Staff trainings

37. 10 year old female

38. 8 year old female

41. 19 year old female

42. 13 year old male

43. SJSD McKinney Vento Initiatives 2010-2011 Priority Level 1 building Staff training Parent training Screening of students Groups of 6-8 students, highest need using SITCAP model School Counselor and Social Workers training Trauma questions on local mental health centers assessment /intake forms Community training for clinicians which included key shelter staff

44. 2011-2012 Shelter trainings Parent support group Counselors, social workers and community certifications In-school one-on-one sessions with students

45. What does it mean for your agency to be trauma informed? Safety Structure Becoming a witness We must be aware of how our own experiences effect our ability to help

46. The Importance of Safety People are not successful in environments where they do not feel physically and emotionally safe, heard, and respected. For people who have experienced trauma, issues of safety become even more prominent.

47. Safety continued Creating Consumer Crisis Prevention Plans A written, individualized consumer self-care or crisis-prevention plan should include the following: A list of situations that the consumer finds stressful or overwhelming and remind him/ her of past traumatic experience (i.e., triggers). Ways that the consumer shows that he/she is stressed or overwhelmed (e.g. types of behaviors, ways of responding, etc.). Staff responses that are helpful when the consumer is feeling upset or overwhelmed. Staff responses that are not helpful when the consumer is feeling upset or overwhelmed. A list of people to go to for support. A list of situations that the consumer finds stressful or overwhelming and remind him/ her of past trauma.

48. Importance in Assessment Process Programs serving families who are experiencing homelessness have an opportunity to address children’s needs and connect them to appropriate services. To meet children’s needs, questions about their exposure to trauma must be included in the intake assessment.

49. Policies Homeless children are often required to spend part of their days alongside their parents negotiating the hierarchical maze of social service agencies that might provide them with a place to sleep.

50. Sense of Control? When children are sheltered, they must learn and then conform to new rules which dictate what time and under what conditions they eat, sleep, shower, leave and/or return to a building Living in a shelter setting challenges pre-existing family rituals and unbalances the authority of parents creating disharmony for adults and children alike.

51. Separation Entering shelters may also result in forced separations from parents and siblings due to program restrictions that exclude fathers and/or adolescent boys. Shelters crowded with strangers of all ages, some of whom may be emotionally unbalanced or aggressive, may create destabilizing and unsafe environments for children.

52. Judith Herman Quote “Atrocities refuse to be buried…..Remembering and telling the truth about terrible events are prerequisites both for restoration of the social order and for the healing of individual victims.”

53. “When the broken window was repaired and the stove began to spread it’s heat, something seemed to relax in everyone, and at that moment one prisoner proposed to the others that each of them offer a slice of bread to us three who had been working. And so it was agreed. Only a day before a similar event would have been inconceivable. The law of the camp said “eat your own bread, and if you can, that of your neighbor,” and left no room for gratitude. It was the first human gesture among us. I believe that that moment can be dated as the beginning of the change by we who had not died slowly changed from prisoners to humans again.” Quote from Primo Levi, Nazi Concentration Camp Survivor

54. Resources Cowan, Beryl Ann, "Trauma exposure and behavioral outcomes in sheltered homeless children: The moderating role of perceived social support" (2007). Psychology Dissertations. Paper 39. http://digitalarchive.gsu.edu/psych_diss/39http://digitalarchive.gsu.edu/psych_diss/39 HCH Health Care for the homeless Clinician’s network. Trauma and Homelessness.(1999) Vol.3, No.3 HCH Health Care for the homeless clinician’s network. Homelessness and family trauma: The Case for early intervention. (2003) Vol. 7, No. 2 Hermin, J. (1992) “Trauma and recovery”. Levine, P. (2005) “Healing Trauma A pioneering program for restoring the wisdom of your body.” Sounds true Inc., Boulder CO. NCTSN The National Child Traumatic Stress Network. Facts on Trauma and homeless children. (2005) www.NCTSNet.orgwww.NCTSNet.org www.starr.traing.org/tlc jean.west@sjsd.k12.mo.us